At medicine grand rounds in May 1996, Arthur Rubenstein, MD, discussed the management of a 64-year-old man with a 26-year history of diabetes mellitus.1 Mr D had endarterectomy for carotid stenosis in 1995 and had a right foot drop and peripheral neuropathy. His diabetes was managed with diet, exercise, and glipizide, but he had occasional hypoglycemia. Just prior to the conference, metformin was added to his regimen. He did not check blood glucose levels at home. In the office blood glucose levels ranged between 10.3 mmol/L (185 mg/dL) and 21.9 mmol/L (395 mg/dL), with a hemoglobin A1c (HbA1c) level of 9.1% (normal, 4.4%-6.4%) prior to starting metformin. The patient did not want to take insulin.

Dr Rubenstein discussed the epidemiology of adult-onset diabetes and suggested there is growing evidence that aggressive management of blood glucose, along with exercise, weight control, and lipid control, may decrease morbidity. He